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Content Article Comment
The systemic silent killer – ending the stigma around whistleblowing: a blog by Steve Turner
richard vA commented on Steve Turner's article in Whistle blowing
- Patient harmed
- Flawed processes
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Please respond to this summary of a harmful system for whistleblowrs, so patients https://minhalexander.com/2017/04/08/engineered-failure-to-investigate-nhs-whistleblowers-concerns/- Posted
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- Patient harmed
- Flawed processes
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Content Article Comment
The systemic silent killer – ending the stigma around whistleblowing: a blog by Steve Turner
richard vA commented on Steve Turner's article in Whistle blowing
- Patient harmed
- Flawed processes
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There are many very differing views on the crisis and scandal around NHS whistleblowrs and a much less optimistic account by a remarkable fearless campaigner is linked below deserving coverage on this site. There are real dangers of powerful interests causing additional mayhem, and I am not exaggerating one iota ! https://minhalexander.com/2023/05/09/the-whistleblowing-hunger-games-why-we-should-reject-the-whistleblowing-appg/- Posted
- 5 comments
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- Patient harmed
- Flawed processes
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Content Article Comment
World Patient Safety Day 2023
richard vA commented on Patient Safety Learning's article in WHO
- WPSD23
- Patient engagement
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Let's focus on patient empowerment element. That is where most change potential resides. No sign. Patient voices, issues, concerns, insights are actively excluded from safety learning process too often. We need Patient Leadership in processes. Great ideas developed by David Gilbert at InHealth but so very very little done along these lines. Even just reporting (eg here attached) or including in so called model 'engagement ' processes. No evidence sought. More to report from the front line soon.- Posted
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- WPSD23
- Patient engagement
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Content Article Comment
How can patients' voices be heard and acted upon when they attempt to report incidents of harm?
richard vA commented on richard vA's article in Patient stories
- Patient harmed
- Patient suffering
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Little Optimism. When I see the lack of harmed patient voices at the new Patient Safety Commissioners advisory body I wonder how and why the voice of patients, without any other interest apart from harm prevention and learning , are still kept away from the centre. What do governing bodies fear and are trying to hide, deny, cover up, under play? Very worrying, annoying, heart breaking, infuriating... legitimate feelings at this time.- Posted
- 10 comments
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- Patient harmed
- Patient suffering
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Content Article Commentshocking.sickening.perhaps HSIB expert system investigation needed, not sure if it meets criteria https://www.hsib.org.uk/who-we-are/about-hsib/ as loing as patient voice adequately heard throughout any review
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- 1 comment
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- Womens health
- Surgery - Obs & Gynae
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Content Article Comment
Presentation from Linda Kenward: Engaging patients and service users for safety (October 2019)
richard vA commented on Patient Safety Learning's article in How to engage for patient safety
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Simple but powerful points Which organisations have engaged with this ? I know one patient leader who leads the way, but not primarily in patient safety : David Gilbert I know one safety expert who respects patient expertise. I will not name her. I urge her to speak out more on this! When patient safety is personal. For both sides My experience is patients are kept at bay, all extra work done to protect services. Especially in how the story is told! The starting point. And so from harmed patient perspective where bias, being ignored, dis respected, powerless ..all starts....and so never ends. Never resolved. And so very little learning emerges. It takes exceptional patients like JamesTitcombe to get their story heard.told and re told. Exceptions prove the rule. So wrong. Unhealthy. Excluding. Uneducating . And literally dangerous for patients, and also the vital alliance they should be building with health care staff and systems who truly want to improve. Dangerous. Deadly. And Wrong.- Posted
- 1 comment
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- Communication
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Content Article Comment
NES: Safety culture discussion cards
richard vA commented on PatientSafetyLearning Team's article in Good practice
- Safety culture
- Teamwork
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1. Does this mean anything without a safety learning system? HSIB looking at that. And that can be anything 2.without Whistle-blowers protection which does not exist , follow Minh Alexander and 3.without a proper independent expert route for patients to report harm events ( not complaints system)? ( latter on for consultation sometime, somewhere, I fear plans to be scrapped by NHSEpatientsafety). I am very pessimistic and considering leaving the game where patients voices are fundamentally excluded despite token gestures, rhetoric, recognition things could be much better......- Posted
- 2 comments
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- Safety culture
- Teamwork
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Content Article Comment
NES: Safety culture discussion cards
richard vA commented on PatientSafetyLearning Team's article in Good practice
- Safety culture
- Teamwork
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(and 3 more)
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1. Does this mean anything without a safety learning system? HSIB looking at that. And that can be anything 2.without Whistle-blowers protection which does not exist , follow Minh Alexander and 3.without a proper independent expert route for patients to report harm events ( not complaints system)? ( latter on for consultation sometime, somewhere, I fear plans to be scrapped by NHSEpatientsafety). I am very pessimistic and considering leaving the game where patients voices are fundamentally excluded despite token gestures, rhetoric, recognition things could be much better......- Posted
- 2 comments
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- Safety culture
- Teamwork
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Content Article CommentHow will patients voices be central when there is no patient harm reporting system with independent experts which is easily accessible and fit for purpose. In fact it is up for being phased out. and when you Henrietta say it is not a subject for your office. Deeds not words is what patients families want and need NOW . one year on no progress just more deaths, harm and institutional scandals
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- 1 comment
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- Commissioner
- Patient
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Article Comment
CQC brings in whistleblowing gurus to boost ‘independence and credibility’
richard vA commented on Patient Safety Learning's news article in News
- Whistleblowing
- Speaking up
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I believe this needs more coverage on the hub I draw your attention to an excellent campaigner leading the way with two recent tweets saying it all https://twitter.com/alexander_minh/status/1613818537046417409?t=fomCyxh5kpG6FGM0uBBZHA&s=19 https://twitter.com/alexander_minh/status/1614040424192299013?t=gHcO3CZxXJtjDn-W8Dlk9Q&s=19 Richard Patient safety advocate from patient family perspective Without whistleblowrs protection and empowerment little change can be achieved- Posted
- 1 comment
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- Whistleblowing
- Speaking up
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Article Comment
NHS whistleblower wins £500,000 for unfair dismissal
richard vA commented on Patient Safety Learning's news article in News
- Whistleblowing
- Speaking up
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I believe this needs more coverage on the hub I draw your attention to an excellent campaigner leading the way with two recent tweets saying it all https://twitter.com/alexander_minh/status/1613818537046417409?t=fomCyxh5kpG6FGM0uBBZHA&s=19 https://twitter.com/alexander_minh/status/1614040424192299013?t=gHcO3CZxXJtjDn-W8Dlk9Q&s=19 Richard Patient safety advocate from patient family perspective Without whistleblowrs protection and empowerment little change can be achieved- Posted
- 2 comments
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- Whistleblowing
- Speaking up
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Content Article Comment
Harmed Patient Safety Governance role: An open letter from a patient safety campaigner
richard vA commented on richard vA's article in HSSIB investigations
- Patient engagement
- Patient / family involvement
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Here is the advert. I think it is an important opportunity for a patient perspective to be institutionalised in what hopes to develop as an exemplar service https://apply-for-public-appointment.service.gov.uk/roles/5141- Posted
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- Patient engagement
- Patient / family involvement
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Content Article CommentTa. Yes I wrote about it here I fear it will be downgraded even further. Patient leaders as worked out and articulated by David Gilbert vital. This paper below should be adapted for harmed Patient learning. I am starting on something. Anyone there on hub team or linked want to help co write something? Ta Richard CentreforMentalHealth_HumanisingHealthCare.pdf
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- 3 comments
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- Womens health
- Medication
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Content Article CommentWill you be interviewing the new Patient Safety Commissioner perhaps asking questions based on those raised by a blog here. I would focus mine on the vital value of harmed patients being in a leadership role in her Office and all undertakings, and consider role of patients reporting harm events as there is no current system used.i could say more!
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- 3 comments
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- Womens health
- Medication
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Content Article Commenta damning indictment on the non existent and at best very fragmented tokenistic patient safety system. my only comment is more attention must be paid to patients views throughout the processes, which currently are even worse than the system itself. 1. Even reporting of harm is not catered for, but pushed to a complaints model or a now very restricted incident investigation system PSIRF where i cannot see a strong patient voice. This needs remedy as i argued earlier this year and this is on the backburner and probably will be downgraded further from what i have heard read here when i was slightly more optimistic 2. but more substantially the patient voice needs to be empowered as is increasingly recognised in some services, like mental health and the same needs to be done for the whole safety and harm investigation and learning process. i refer to a leading expert in this area https://www.centreformentalhealth.org.uk/publications/humanising-health-care
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- 1 comment
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- Leadership
- Just Culture
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Content Article Commenta damning indictment on the non existent and at best very fragmented tokenistic patient safety system. my only comment is more attention must be paid to patients views throughout the processes, which currently are even worse than the system itself. 1. Even reporting of harm is not catered for, but pushed to a complaints model or a now very restricted incident investigation system PSIRF where i cannot see a strong patient voice. This needs remedy as i argued earlier this year and this is on the backburner and probably will be downgraded further from what i have heard read here when i was slightly more optimistic 2. but more substantially the patient voice needs to be empowered as is increasingly recognised in some services, like mental health and the same needs to be done for the whole safety and harm investigation and learning process. i refer to a leading expert in this area https://www.centreformentalhealth.org.uk/publications/humanising-health-care
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- 1 comment
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- Patient harmed
- Recommendations
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Content Article Comment
Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report
richard vA commented on Patient Safety Learning's article in Trust investigations
- Investigation
- Recommendations
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agree with above further: 1. until patients reports on harm events are properly requested and responded to (there is no single harm focused expert system- then the insights and expereinced of patients will be lost, ignored, unheard, taken as a @complaint' 2. until patients and their advocates as Berwick argued are empowered in all aspects of the system, not merely tokenistic as editors, campaigners, writers then there will be no pone with pure patient interests to fight for change. we need patient leaders, the work of David Gilbery shows how it should be done https://www.inhealthassociates.co.uk/articles-reports/ and attached. empowering those harmed throughout the system is vital CentreforMentalHealth_HumanisingHealthCare.pdf- Posted
- 3 comments
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- Investigation
- Recommendations
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Content Article Commentplease provide accessible version
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- 1 comment
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- Patient safety strategy
- Leadership
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Content ArticleThis open letter from patient safety campaigner Richard von Abendorff calls for patients, their families and safety campaigners to help improve patient investigation and patient inclusive systems. Richard highlights a new role coming up at the new Health Services Safety Investigations Body (HSSIB).
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- 1 comment
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- Patient engagement
- Patient / family involvement
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Event Comment
Just Culture and incident investigation
richard vA commented on Patient Safety Learning's event in Community Calendar
- Just Culture
- Investigation
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- 1 comment
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- Just Culture
- Investigation
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Content Article Comment
Please don’t undermine my pain relief! A call for learning and respect for patients with long term needs
richard vA commented on richard vA's article in Pain management
- Patient harmed
- Patient suffering
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The Royal College of Emergency Medicine have a Safe Care Committee which are considering the question! I am hopeful. A valuable forum for others here to consult? https://rcem.ac.uk/safety-3/#:~:text=What%20is%20the%20Royal%20College,the%20speciality%20of%20Emergency%20Medicine- Posted
- 5 comments
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- Patient harmed
- Patient suffering
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Content Article Comment
How can patients' voices be heard and acted upon when they attempt to report incidents of harm?
richard vA commented on richard vA's article in Patient stories
- Patient harmed
- Patient suffering
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Watch for update. Further delays in any improvement at all so continuing failure to allow patients families and public to properly record harm events . Dangerous health care where and when it occurs allowed to continue- Posted
- 10 comments
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- Patient harmed
- Patient suffering
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Content Article Commentseem my comments in PSH blog on this letter. more concerns..
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- 1 comment
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- Leadership
- Safety culture
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Content Article Comment
HSIB: Blog - Knowledge exchange with Norway (28 June 2022)
richard vA commented on Mark Hughes's article in Investigations and complaints
- Investigation
- Information sharing
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interesting differences...less hierarchical question: in role of patients, families, scoping of investigations?- Posted
- 1 comment
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- Investigation
- Information sharing
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Content Article CommentPatients need more than 'engagement'. I will write more soon following being engaged in various processes over the last 11 years. Experts by experience need to be at the core of all processes. Understanding the harm and its consequences, and restorative learning and justice are essential . The interests of patients and communities of patients including harmed and neglected patients must spearhead this culture change. It hasn't even started. The treatment of whistleblowers and patients complaints via Trusts and PHSO illustrate the profound second level harms and injustices being perpetuated, opposite to the learning from harm perspective urgently required.
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- 2 comments
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- Patient safety strategy
- Safety culture
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